JOURNAL OF PALLIATIVE MEDICINE

Volume 8, Supplement 1, 2005

© Mary Ann Liebert, Inc.

Interventions to Enhance Adaptation to Bereavement

HENK SCHUT, Ph.D. and MARGARET S. STROEBE, Ph.D.

ABSTRACT

This paper reviews quantitative evaluations of the efficacy of intervention programs designed
to reduce the pain and suffering associated with bereavement. After identifying the psycho-
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logical and physical health impacts of bereavement and outlining the prevalence of detri-
mental outcomes, we conclude that a minority of bereaved persons experience severe and
sometimes lasting consequences, whereas the majority manage to overcome their grief across
the course of time. We detail criteria for establishing the efficacy of bereavement interven-
tion and examine the impact of intervention according to these stringent criteria. We critically
examine previous reviews and summarize their conclusions. Using a narrative review ap-
proach, we apply a public health framework to organize intervention programs into primary,
secondary, and tertiary prevention strategies. A comprehensive, updated review of empirical
studies in these categories leads to the following conclusions: Routine intervention for be-
reavement has not received support from quantitative evaluations of its effectiveness and is
therefore not empirically based. Outreach strategies are not advised, and even provision of
intervention for those who believe that they need it and who request it should be carefully
evaluated. Intervention soon after bereavement may interfere with “natural” grieving pro-
cesses. Intervention is more effective for those with more complicated forms of grief. Finally,
a research agenda is outlined that includes the use of rigorous design and methodological
principles in both intervention programs themselves and in studies evaluating their efficacy;
systematic investigation of “risk factors”; and comparison of relative effectiveness of differ-
ent intervention programs (i.e., what works for whom).

INTRODUCTION ments (ESTs) is becoming a more standard re-

quirement.1 Bereavement intervention programs

D O PEOPLE WHO LOSE a significant person in

their lives through death actually need help
from counselors or therapists to adapt to their
loss? Do such interventions really help bereaved
individuals to adjust? Such questions have been
the subject of considerable debate and a growing
number of empirical investigations in recent
years. The issues involved are critical. Today,
psychological intervention is more often put to
stringent empirical test for its efficacy, and the
implementation of empirically supported treat-
need to be empirically assessed for their effec-
tiveness and associated costs to bereaved indi-
viduals and to society.2 It is also important to es-
tablish that intervention efforts are directed to
those bereaved who need and benefit most from
them. In this paper, we examine the ability of
bereavement intervention programs to reduce
symptoms of grief, to prevent or cure complicated
grief, and to mitigate long-term negative conse-
quences of bereavement. We use stringent crite-
ria to review the empirical studies of the efficacy

Department of Clinical Psychology, Utrecht, the Netherlands.

S-140
 INTERVENTIONS IN BEREAVEMENT
of intervention programs, and we draw conclu-
sions about the helpfulness of bereavement in-
terventions.
OCCURRENCE AND PREVALENCE
OF MENTAL AND PHYSICAL
HEALTH PROBLEMS
Bereavement (the situation of a person who has
recently experienced the loss of someone signi-
ficant—notably a parent, partner, sibling, or
child—through that person’s death) is well-rec-
ognized as a debilitating experience, one that
causes a great deal of emotional pain. Neverthe-
less, before considering issues concerning inter-
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vention to enhance adaptation to bereavement,
the health impact and prevalence of problems in
bereavement need to be more precisely identified.
There is, in fact, a substantial body of scientific
research on the consequences of bereavement.2,3
Bereavement can be viewed as a normal, natural
human experience, one that is part of nearly
everyone’s life, even an essential element of the
human condition. Studies have shown that most
individuals manage to come to terms with their
bereavements over the course of time, in many
cases even emerging with “new strength” as time
goes on and new challenges are mastered. How-
ever, it has also become evident that bereavement
is associated with a period of intense suffering for
the majority of individuals and with an increased
risk of negative mental and physical health out-
comes for some. Adjustment can take months or
even years. Reactions are subject to substantial
variation, both among individuals and across cul-
tures. Furthermore, although most individuals
eventually recover from their grief and its ac-
companying symptoms, for a substantial minor-
ity mental and physical ill health is extreme and
persistent. Death of a loved one even increases
the mortality risk for the survivor. This effect has
been empirically well substantiated after partner
loss and, more recently, among parents who have
lost a child.3,4
How prevalent are psychological and physical
health problems after bereavement? Prevalence
rates for the various health detriments vary not
only according to the particular debility in ques-
tion but also across investigations of different be-
reaved samples.5 Consistently, however, in a mi-
nority of cases the psychological reactions are so
severe as to reach levels equivalent to the diag-
S-141
nostic criteria for mental disorder. A review of
studies of pathological grief reported estimates
from different studies ranging from 5% to 33%
among acutely bereaved persons.5 However, it is
difficult to know precisely how to interpret such
prevalence rates for pathological grief because
criteria have not been established and the defini-
tion of pathological grief (also labeled traumatic
or complicated grief) remains imprecise. At this
point we need to be cautious in drawing conclu-
sions about the incidence and prevalence of
pathological grief.*
With respect to other bereavement-related dis-
orders, although 50% of a spouse-bereaved sam-
ple in one study reached the criteria for diagno-
sis of post-traumatic stress disorder (PTSD) at one
of four points of measurement (first 2 years of be-
reavement), only 9% met this level at all four
points.6 In another study, young persons who
had experienced the violent loss of a significant
person in their lives and who had no previous
history of trauma had high rates for PTSD and
acute stress disorder.7 Of those participants, 22%
met lifetime criteria for a trauma-related diagno-
sis combining acute stress and PTSD. With re-
spect to affective disorders, 42% of widowed per-
sons have been found to reach levels equal to or
above the cut-off point for mild depression 4–6
months after loss, compared to 10% of married
persons.8 In this study, the depression rate de-
clined to 27% after 2 years, still significantly
*Pathological grief is not (yet) a diagnostic category of
mental disorder, and any agreed-on standard for diag-
nosis is so far still lacking (although scientists are cur-
rently working hard to validate classification procedures
and come to better consensus.32 This state of affairs is in
contrast to the Post Traumatic Stress or Major Depressive
Disorders categories that have established criteria and
cut-off points in, for example, the Diagnostic and Statis-
tical Manual of Mental Disorders.33 Classification of
pathological grief at present is frequently based on a
somewhat arbitrary statistical cut-off point (e.g., the top
20% of scores on a complicated grief scale are classified
as reflecting pathological grief). Another problem relates
to the fact that there may be other forms of pathological
grief than persistent, debilitating “chronic grief” that is
closest to proposed DSM criteria.3 Some researchers have
described absent, inhibited, or delayed grief as patholog-
ical34 categories that are also well-recognized by grief
therapists whereas others deny the existence of such cat-
egories.35 Jacobs and Prigerson3 acknowledged that sub-
types such as delayed or inhibited grief may not be iden-
tifiable in their proposed criteria. Following these
arguments, we need validation of criteria and consensus
on types of pathological grief before we can make firm
statements about its prevalence.
 S-142
higher than for married persons. According to
Zisook and Shuchter,9 major depressive syn-
dromes have been found to occur in 24–30% of
widowed persons 2 months after the death, ap-
proximately 25% at 4 months, and 16% at 1 year.
Research on physical ill health has consistently
reported elevated rates among bereaved persons
on measures of physical symptoms, doctor visits,
use of medication, disability, and hospitaliza-
tion.3 For example, in one study, 20% of widowed
(as compared to 3% of married) individuls scored
above the cut-off point for severe physical symp-
toms 4–6 months after the loss. This rate declined
to 12% after 2 years.8 Mortality is a dramatic con-
sequence in terms of risk; but in terms of actual
numbers, very few bereaved individuals die as a
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result of their loss.3
In conclusion, we can infer from the various
prevalence rates that there are marked differences
among bereaved persons, not only with respect
to the intensity of their grief reactions but also
with respect to the types of complication and pat-
terns of comorbidity that they may experience.10
Even though the severe effects on mental and
physical health outlined above appear to affect
only a minority of bereaved persons, the preva-
lence rates are of sufficient magnitude to cause
societal concern.
Intervention: definition and efficacy criteria
To answer the questions “Is intervention for
the bereaved necessary?” and “Is intervention ac-
tually effective?” we must first define “interven-
tion.” The range of potentially available behav-
ioral interventions in current western society
includes crisis teams visiting family members
within hours of a loss; self-help groups with the
goal of fostering recognition and friendship; pro-
grams to educate bereaved individuals about
working through grief; cognitive restructuring
and behavioral skills programs; treatments in-
volving the sharing of information, emotions, and
support; brief group psychotherapy, as well as
behavior therapy, hypnotherapy, and dynamic
therapy.11,12 It is useful here to confine the scope
to consideration of organized or institutionalized
counseling or therapy. Types of intervention for
the bereaved vary from voluntary counseling for
bereaved persons in so-called “self-help” aid to
individual or family therapy programs designed
to help when grief complications have arisen.13,14
We focus here on help that is specifically aimed
at bereaved persons (thereby excluding, for in-
SCHUT AND STROEBE
stance, palliative care, which is primarily in-
tended for the dying) and that provides person-
to-person support, either individually or in
groups.
As we noted in our earlier review,15 the basic
principle underlying any provision of interven-
tion is that it benefits the bereaved person in
terms of mitigating the emotional and practical
problems that have been experienced after the
loss of a loved one. Researchers must establish
that the psychological treatments for bereaved
persons have been demonstrated to be efficacious
in controlled research with a delineated popula-
tion.1 As a starting point, reviewers need to set
up stringent criteria to structure the evaluation of
treatments, following as closely as possible the
empirically supported treatment criteria pro-
vided in the general psychological treatment lit-
erature.1 Establishment of the efficacy of be-
reavement intervention needs to be based on the
following:
1. Empirically tested intervention programs. Fre-
quently, judgment is based on subjective assess-
ments made by the bereaved persons themselves
who report their satisfaction with the interven-
tion program and its benefits in overcoming
problems. Clearly, such reports are subject to bi-
ases. For example, dissatisfied dropouts are typ-
ically not counted; people may respond in a man-
ner that is desirable, having committed
themselves to continue in a program; and re-
spondents may say nothing in terms of actual
change.
2. Methodologically sound research designs. Major
shortcomings in bereavement intervention
efficacy studies still remain:
• Control groups. Many studies still lack a no-
treatment-control group or placebo group
comparison condition.15† Grief is a process that
is expected to change over time, so if there is
no non-intervention control group, it is im-
possible to attribute effects to the intervention
itself. Furthermore, it is conceivable that the
grief intervention may do harm rather than
†Alternative treatment groups provide a potential con-
trol group condition too,1 but well-established interven-
tions (i.e., those well-described and transferable, with
treatment manual, tested, replicated and found effective,
and accompanied by indications and counter-indications)
are not available in the area of grief counseling).
 INTERVENTIONS IN BEREAVEMENT
good, an effect that also must be measured
against a no-treatment control.
• Participant assignment procedures. Assign-
ment to conditions should be random or by
matched assignment. For example, a compari-
son of accepters versus decliners of the inter-
vention is not a valid assessment of efficacy,
because there are likely to be systematic dif-
ferences between the groups.
• Consideration of nonresponse and attrition.
Bereavement intervention studies typically
have low acceptance and attendance rates.15
Yet nonresponse and attrition can seriously in-
fluence results and affect generalizability. For
example, participants may be more depressed
than nonparticipants. Those who drop out may
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be less depressed, may have recovered, or may
have benefited least.
• Reasonable levels of adherence. Absence from
sessions or high dropout in control conditions
can seriously bias evaluation of efficacy of an
intervention program. Existing studies differ
markedly in adherence, from hardly any ab-
sences to as little as 30% regular attendance.15
Adopting the strict criteria outlined above for
efficacy studies necessitates excluding considera-
tion of several kinds of counseling: for example,
pastoral care, intervention by medical doctors,
and support from funeral directors. This is not to
deny the potential importance of these types of
intervention. They have simply not, to our knowl-
edge, been adequately put to the test.
Reviews of efficacy studies
There are many individual studies and a few
reviews on the efficacy of intervention programs
in helping the bereaved to adapt to their loss.
Some reviews cover the whole range of bereave-
ment interventions for a variety of bereavements,
adopting either meta-analytic and/or narrative
approaches.15–18 Others are more limited with re-
spect to the type of bereavement (Curtis and New-
man19 focused their review on benefits of inter-
vention for children), type of intervention (Jacobs
and Prigerson7 focused specifically on psy-
chotherapeutic treatment), or specific bereave-
ment-related pathology (Zisook and Shuchter9 fo-
cused on so-called depressions of bereavement).
Additional authors have provided secondary re-
ports of the primary reviews noted above.2,16
There are other similarities and distinctions be-
tween the major reviews, both in selection crite-
S-143
ria and in the conclusions drawn about efficacy.
We summarize and evaluate these reviews next.
Comprehensive reviews. Kato and Mann17 fo-
cused on the efficacy of group versus individual
intervention, using selection criteria that required
random assignment to treatment versus control
groups, similar recruitment procedures for both
groups, and post-bereavement initiation of inter-
vention. These reviewers concluded that there
were methodological flaws in most of the studies
and that neither group nor individual interven-
tion had been shown to be particularly effective.
Litterer, Allumbaugh, and Hoyt18 provided an in-
depth review that also included meta-analysis
but that did not impose stringent criteria for se-
lecting studies. In contrast to the Kato and
Mann17 review, they concluded that intervention
was helpful and, in particular, they argued for
help soon after bereavement. The limited atten-
tion to methodology raises doubts about these
conclusions. The overall quality of efficacy stud-
ies of grief intervention is frequently too poor to
permit meta-analysis. There are huge differences
between studies, making it extremely difficult to
carry out detailed standardized comparison
across studies. Furthermore, when meta-analysis
is conducted, important information necessarily
gets lost. For example Litterer, Allumbaugh, and
Hoyt18 excluded longer-term follow-up effects of
intervention from investigation because too few
of the studies included follow-up data. Yet this
information is critical because the general aim of
intervention is to achieve enduring effects. Lit-
terer, Allumbaugh, and Hoyt18 may have come
to less positive conclusions about the efficacy of
intervention had they included long-term assess-
ment. In addition, these reviewers made no dis-
tinction between different types of bereavement
intervention in assessing efficacy. An evaluation
of which types of interventions help which
groups of bereaved persons is critically needed.
We previously presented a narrative review15
based on a public health framework, whereas
other reviews have lacked theoretical structure.
We based selection of the studies for review on
the stringent criteria defined above. We also cat-
egorized studies into different types of interven-
tion, following the well-established distinctions
described by Caplan.20 The review covered both
short- and long-term effects of bereavement in-
tervention. We concluded that intervention was
differentially effective according to the degree of
complication in the grieving process (as detailed
 S-144
below). However, we presented this conclusion
tentatively because we recognized that method-
ological shortcomings were a major obstacle to
establishing efficacy.
Limited-scope reviews. Curtis and Newman19 re-
viewed the efficacy of a range of community-
based interventions for bereaved children, re-
porting limited empirical evidence and
considerable methodological weaknesses in de-
signs. They concluded that the case for universal
inclusion of children in support programs re-
mains unproved. Jacobs and Prigerson6 reviewed
evidence specifically for the treatment of their
proposed new diagnostic entity of traumatic
grief. Because no interventions had been de-
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signed for this diagnosis, the review covered ex-
isting psychotherapeutic treatments. The cover-
age and conclusions were similar to those in our
2001 review15 Zisook and Shuchter9 reviewed in-
terventions specifically for bereavement-related
major depressive disorders, noting that the onset,
exacerbation, or persistence of this type of dis-
order are among the most frequently encountered
complications of bereavement. Surprisingly,
therefore, they found very few well-controlled
studies of the treatment of bereavement-related
depression. Although evidence suggests that in-
tervention could prevent complications in high-
risk populations, no studies were available to es-
tablish efficacy specifically for individuals with
past personal histories of major depression.
Secondary reports. Jordan and Neimeyer16,21
summarized some of the above qualitative (nar-
rative) and quantitative (meta-analytic) reviews
of the literature on the efficacy of individual and
group interventions, primarily for adults, in-
cluding a report of an unpublished meta-ana-
lytic review by Fortner and Neimeyer. Their
conclusions were more in line with those of Kato
and Mann17 and our previous paper15 than with
Litterer, Allumbaugh, and Hoyt.18 Evidence for
the efficacy of grief intervention is quite weak.
Most recently, Genevro2 provided a concise
overview, based largely on our previous re-
view15 and that of Jordan and Neimeyer,16 and
drawing conclusions consistent with those pre-
ceding reviewers.
Overview of empirical studies
For the current paper we updated our review
of the literature to see whether problems with de-
SCHUT AND STROEBE
sign and methodology and shortage of studies
have been overcome. We follow the approach we
used in our earlier review,15 observing the strin-
gent criteria outlined above in providing a criti-
cal assessment of the available studies of be-
reavement intervention programs. In this section,
we first summarize our previous findings15 and
then extend this review to include studies that
have appeared since that review and meet the
identified criteria. As before, a qualitative rather
than quantitative approach is followed. Exami-
nation of the studies revealed that there are still
an insufficient number of methodologically com-
parable and rigorous studies to use meta-analyt-
ical techniques.
The efficacy of primary, secondary, and tertiary pre-
vention. As in 2001,15 we subdivided bereavement
interventions into three types. (1) General or pri-
mary prevention interventions are open to all be-
reaved persons, to anyone who has experienced
a loss through death. Sometimes these interven-
tions are targeted toward specific subgroups of
the bereaved (for example, bereaved parents or
spouses). Primary prevention is directed toward
those who are experiencing uncomplicated be-
reavement. (2) Secondary prevention interven-
tions are designed for bereaved persons at high
risk, that is, for those who are deemed for one
reason or another to be likely to experience a com-
plicated form of grief. Examples would be death
through homicide or the concurrent loss of mul-
tiple family members under traumatic circum-
stances. (3) Tertiary prevention interventions are
targeted toward persons who are experiencing
complications in their grieving process. Treat-
ment of bereaved persons with depressive dis-
orders would fit in this category, as pre-existing
pathology is present. Treatment involves imple-
menting psychotherapeutic treatment techniques
specifically aimed to alleviate complicated or
pathological grief and associated disorders.
In our 2001 review,15 16 studies fell into the
primary prevention category, although many
were methodologically flawed. We concluded
then that “primary preventive interventions re-
ceive hardly any empirical support for their ef-
fectiveness. The rare positive effects that are found
often seem only temporary, and sometimes nega-
tive results of the intervention have been reported
too.” However, we also noted that primary pre-
vention for bereaved children can be effective.
Fewer (seven) studies fell into the secondary pre-
 INTERVENTIONS IN BEREAVEMENT
vention category, and results were somewhat
mixed. Effects, if found, were rather modest, and
there were some indications that improvement
was only temporary. Screening for high risk
seemed to increase efficacy. Finally, seven studies
of the efficacy of tertiary prevention interventions
were available. Most of these studies found posi-
tive and lasting results, although they too were of-
ten modest. In general, the quality of the tertiary
prevention studies was higher than those in the
other categories (e.g., pre–post control design).
Importantly, in these latter studies, the provision
of intervention was based on a request for—rather
than an offer of—help.
Review update. A comprehensive search of the
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MEDLINE and PsycInfo databases identified 30
additional studies of intervention efficacy that
have been published since our previous review.15
Many are still methodologically unsound, a strik-
ing problem being the continued absence of con-
trol groups. Only seven of these newer studies
met the design criteria and will be reviewed here.
Four of these fell within the primary cate-
gory.22,25 Generally better results were found in
these studies than in the earlier ones.‡ These stud-
ies also contrasted with earlier ones in that all but
one used inreaching procedures: that is, inter-
vention was given to those who requested it
themselves rather than being offered it on an out-
reaching basis. Thus, contrary to earlier studies,
participants in these newer programs were self-
selected. The outreaching procedure used in the
earlier studies was regarded as a possible expla-
nation for the lack of positive results or the pres-
ence of negative results.15 The newer studies sug-
gest that an inreaching primary prevention
strategy leads to better results. The one out-
reaching study22 found positive results only with
the high-risk group. Another possible explana-
tion for the better results of the more recent in-
reaching studies was that they provided inter-
vention later in bereavement (after several
months or years), which had also been suggested
as a more effective procedure. Further studies are
needed to determine the relative importance of
the time and inreach and outreach factors in con-
tributing to efficacy.
‡The efficacy of intervention in the Goodkin et al.22
study is questionable. Significant pre- to post-interven-
tion improvements were reported (sometimes for the con-
trol group too) but no significant interactions were re-
ported, to indicate relatively better improvement for the
intervention compared with the control group.
S-145
Only one additional secondary prevention
study was found.26 In this study of children be-
reaved by suicide, those in the intervention group
showed more improvement in depressive symp-
toms than those in a community-care control
group. The primary prevention studies of Sandler
et al24 and Murray et al23 also addressed sec-
ondary prevention. These investigators found in-
tervention to be more effective for high-risk chil-
dren and adolescents who had higher distress at
baseline. Thus, there is now more support for the
efficacy of secondary prevention, at least for chil-
dren and adolescents.
Finally, two recent tertiary prevention studies
have been conducted.27,28 Reynolds and col-
leagues28 investigated the impact of medication
and therapy (alone and in combination) on sub-
jects with bereavement-related major depressive
episodes (onset between 6 months pre-bereave-
ment to 1 year post-bereavement). They found no
significant effect with psychotherapy, whereas
medication alone appeared to be helpful. Piper
and colleagues27 offered time-limited group psy-
chotherapy to patients who had been bereaved
on average 9 years earlier and who met criteria
for complicated grief. This study is somewhat dif-
ficult to interpret because there was no noninter-
vention control. It was further limited by the fact
that assessment was “soon after therapy ended,”
so long-term effects are not known. However,
comparison was made between two different pro-
grams (interpretive and supportive therapy), and
patients in both programs improved in both grief
symptoms and general outcomes.
In conclusion, the more recent studies are quite
consistent with and confirm the patterns that we
identified in 2001.15 The quality of investigation
has improved somewhat since the last review,
and we identified a few well-controlled studies
among the still large number of weak studies.
More fine-grained patterns are beginning to
emerge. For example, newer studies suggest that
the impact of intervention is greater for girls than
for boys.23–25 Future studies should also examine
the interaction of gender and type of therapy.
There has been continued focus on the efficacy of
intervention for bereaved children. Newer stud-
ies support our earlier, tentative conclusion15 that
not only secondary and tertiary but also primary
prevention may be effective for children.25 How-
ever, as Curtis and Newman19 concluded, the
case for universal inclusion in support programs
remains unproved, and the basis for referral
needs careful evaluation.
 S-146
GENERAL CONCLUSIONS
A number of implications can be drawn from
our review of the efficacy of primary, secondary,
and tertiary preventive intervention programs.
First and foremost, the notion that routine inter-
vention should be given simply on the basis that
an individual has experienced a bereavement has
not received support from quantitative evalua-
tions of its efficacy and is thus not empirically
based. This conclusion is endorsed by other re-
viewers16,17 and by leading experts. According to
Raphael and colleagues10 “there can be no justifi-
cation for routine intervention for bereaved persons
in terms of therapeutic modalities—either psy-
chotherapeutic or pharmacological—because
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grief is not a disease” (emphasis added). Simi-
larly, Parkes30 stated, “There is no evidence that
all bereaved people will benefit from counseling
and research has shown no benefit to arise from
the routine referral of people to counseling for no
other reason than that they have suffered a be-
reavement.” He went on to conclude: “To be of
benefit counseling needs to be provided for the
minority of people who are faced with extraor-
dinary stress, who are especially vulnerable
and/or see themselves as lacking support.” Chil-
dren are likely to be a special case, perhaps ben-
efiting even from primary intervention. How-
ever, indications are that not all children need or
benefit from intervention, and strategies of in-
reaching and screening for risk would seem to be
advisable.
Our second conclusion is that provision of in-
tervention soon after bereavement may interfere
with natural grieving processes. Third, outreach
strategies have not been shown to be effective and
are therefore not generally advised. Almost with-
out exception the studies with less favorable re-
sults have been those that used this procedure,
while inreaching interventions have continued to
show better results. Those who seek out and ask
for help are likely to be motivated and to have
trust in counselors or therapists. They may have
suffered more and have a greater need for help.
However, provision of an intervention should be
carefully evaluated even for those who feel that
they need it and who request it. Finally, the more
complicated the grief process, the better the
chances that an intervention will be effective.
These conclusions all emerge from a comparison
of the general effectiveness of primary, sec-
ondary, and tertiary prevention programs.
Research improvements still need to be made.
SCHUT AND STROEBE
Bereavement intervention programs themselves
should be tightly designed, and studies evaluat-
ing their efficacy should follow stringent design
and methodological principles. Interventions that
are based on “inreaching” need further develop-
ment to see whether efficacy can be improved to
match interventions with an “outreaching” strat-
egy. Furthermore, systematic comparison of the
relative effectiveness of different therapeutic ap-
proaches is needed. We need to establish answers
to the question, “What works for whom?” We also
need better identification and understanding of
“risk factors” as well as a theoretical frameworks
to guide our research. Finally, American Psycho-
logical Association (APA) guidelines (including
ethical principles) should be applied to imple-
mentation of grief intervention programs as well
as to the investigation of their effects.
More than a decade ago, Robak31 criticized the
bereavement research field for failing to provide
empirical studies on psychotherapy and counsel-
ing: “This is a troubling state of affairs, as it con-
firms an important discrepancy between science
and practice in psychology and perhaps even in-
dicates that practitioners are practicing without
being informed about loss, death and bereave-
ment through empirical work. . . . Not everything
in print is research! Therapists, counselors, and
educators should reexamine the database for their
assumptions. Where are the empirical studies?
They are not in psychotherapy and counseling.”
Although small steps in the right direction are now
being taken, this fundamental message still holds. To
create a body of sound scientific knowledge, the re-
search agenda for the future must expand the num-
ber of well-designed and executed empirical studies
on the efficacy of bereavement intervention.
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Address reprint requests to:
Henk Schut, Ph.D.
Department of Clinical Psychology
Utrecht University
P.O. Box 80140
3508 TC, Utrecht, the Netherlands.
E-mail: H.Schut@FSS.UU.NL